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WASHINGTON, D.C. — The National Transportation Safety Board (NTSB) has released its full report on the fatal 2010 Gray Summit, Mo., crash that involved a pickup truck, a truck-tractor and two school buses.

As SBFreported in December, the NTSB called for a nationwide ban on driver use of nonemergency personal electronic devices while operating a motor vehicle after its meeting on the accident.

In the crash, a pickup truck ran into the back of a truck-tractor that had slowed due to an active construction zone. The pickup truck, in turn, was struck from behind by a school bus. That school bus was then hit by a second school bus that had been following. Two people died, and 38 others were injured in the incident.

The NTSB's investigation revealed that the pickup driver sent and received 11 text messages in the 11 minutes preceding the accident.

NTSB determined that the probable cause of the initial collision was distraction, likely due to a text messaging conversation being conducted by the GMC pickup driver. The agency also found that the second collision, between the lead school bus and the pickup, was the result of the bus driver's inattention to the forward roadway, and the final collision was due to the driver of the following school bus not maintaining the recommended minimum distance from the lead school bus.

Moreover, problems were found with each bus’ brakes. In terms of the lead bus, NTSB found that once power was restored to the bus and the engine was started, neither the ABS warning indicator nor the brake system warning indicator illuminated when the bus was running, and during deceleration testing. In the absence of power and with the engine off, the brakes functioned with manual hydraulic force only.

In addition, the brake lines that ran from the master cylinder to the hydraulic ABS unit appeared to be corroded and leaking, while corrosion was present on a few areas of other brake lines. When the brake pedal on the lead bus was depressed, the movement of the pedal was soft and spongy, and a brake fluid leak was observed in the brake lines running from the master cylinder to the ABS unit. Upon further examination, it was found that one of the bus’ brake lines had a 0.06- by 0.03-inch hole.

In regard to the second school bus, NTSB found that the company that owned the bus had fabricated a spring assembly to help return the brake pushrod from a braking actuation to its non-braking position in an attempt to turn off the service brake application indicator light on the dash. Inspection of the brake lines from the master cylinder to the wheels revealed corrosion in some locations.

The bus was equipped with an ABS ECU, which recorded ABS configuration and diagnostic-related data. Upon examining the data, eight inactive diagnostic fault codes and one active fault code were discovered — this resulted in frequent error signals from the left rear wheel speed sensor. Also, the ABS was not functioning at the bus’ right rear tire.

In addition to the buses' brake problems, NTSB found upon touring the bus company’s facilities that there did not appear to be any set maintenance schedule for the buses or any established method of retaining maintenance records. Neither the owner nor the mechanic had any formal training in the service or maintenance of passenger or heavy-duty vehicles.

NTSB made several recommendations following its investigation of the crash, including that the National Highway Traffic Safety Administration (NHTSA) modify FMVSS 217 to require that all emergency exits on school buses be easily opened and remain open during an emergency evacuation.

The agency also made specific recommendations to the state of Missouri, addressed to the governor. Among them are to revise bus evacuation regulations to require that students traveling to an activity or field trip in a school bus or school-chartered bus be instructed in safe riding practices, and on the location and operation of emergency exits prior to starting the trip.

NTSB also made recommendations to the Missouri Department of Elementary and Secondary Education, CTIA — The Wireless Association and the Consumer Electronics Association, the National Association of State Directors of Pupil Transportation Services, the National Association for Pupil Transportation and the National School Transportation Association, and it reiterated previously issued recommendations.

For example, the agency recommended that NHTSA determine whether equipping commercial vehicles with collision warning systems with active braking and electronic stability control systems will reduce commercial vehicle accidents. If the technology is determined to be effective in this purpose, NTSB would like NHTSA to require its use on commercial vehicles.

The report also includes statements from several NTSB members. Vice Chairman Christopher Hart said that he agrees with most of the findings and the recommendations, as well as the probable cause of the crash, but he has a “concern about how [the NTSB] addressed the issue of driver distraction,” and he added that the recommendation to ban the nonemergency use of portable electronic devices for all drivers “may be scoped too narrowly.”

“Drivers can be distracted just as much by installed electronic devices as by portable electronic devices, so our limitation to portable devices does not fully respond to the problem,” Hart said. “Moreover, portable electronic devices that are designed to support the driving task can be just as distracting as those that are not. Consequently, I believe we should follow up on a suggestion that was mentioned in our Sunshine Meeting for this accident, which is to convene a forum that would look more broadly at the issue of distraction of drivers by electronic devices, both portable and installed.”

Hart suggested that a forum that considers the viewpoints of a variety of experts, as well as the viewpoints of manufacturers, commercial vehicle operators and drivers, could provide a “solid” foundation for the agency to make additional recommendations that more fully and directly focus on the target of driver distraction “without creating unintended consequences, and without resulting in undue or unnecessary burdens.”

Maybe this is another case where 72 passenger school buses should all be equipped with air brakes. I believe that there is more warning systems with air than hydraulic. Also if there is a big loss of air then there are spring brakes that secure the vehicle. My vote is air vs hydraulic. Anyway this is a very tragic accident that may have been avoided if buses where equipped with air brakes. Most if not all medium to heavy vehicles are equipped with air brakes why not school buses.

Ivan | Feb 27, 2012 08:57 AM

Aslo, regardless of how many fingers are pointed, the accident was preventable.

Nancy | Feb 16, 2012 09:18 AM

Distratctions of every kind are all in the day of a school bus driver. Distraction Management programs must be developed and taught.

Nancy | Feb 16, 2012 09:16 AM

There is no justification for not slowing down to avoid a rear end collision. Driver error is the primary reason for this accident. There is also no justification for not having a mechanically sound bus. The brakes did not have to fail to be a contributing factor in this crash. They just didn’t have to work at the level they should have. Poor maintenance, NTSB found upon touring the bus company’s facilities that there did not appear to be any set maintenance schedule for the buses or any established method of retaining maintenance records. At what point did the fatality occur, when the pickup hit the stopped truck or when the bus hit the pickup?

Leon | Feb 10, 2012 07:17 AM

This is just a shame. I sat and read the entire report. I am a bus driver and an instructor. I see nonsense stuff everyday that should not go on. Drivers forget so quickly after they get their license about the very basics. Mechanical failures happen but all too often drivers are the failures and someone needs to stand up and blow the whistle. I wish more people took the responsibility of driving another person's child around more seriously than they do. I tell people all the time, will you be able to look at yourself in the mirror at the end of the day and honestly have no regrets.

Elizabeth Fenton | Feb 09, 2012 03:44 PM

Have a mechanically sound school bus should be a given in the school bus industry. What is being missed by the two previous comments is that driver error was the cause of this tragic crash. The driver of the pickup started the chain reaction because he was using his cell phone (we all think we can use our electronic toys and drive) and rear ended the truck. The two school bus drivers were at fault for following to close to avoid the crash. I may be wrong, but I did not see in the NTSB report, the brakes failed. NTSB reported the it was driver error which caused the crash - so that is where the efforts to improve the safety of our passengers should be made.

Mike | Feb 08, 2012 07:21 AM

I consider the NTSB trustworthy well beyond that of any gov agency out there. They have no bones to pick, protect no one, and seem little to no politics in their reports. A rather terse agency that presents reports that I believe can be trusted. I also wonder why it is so many of these sorts of cases reveal such poor state monitoring. I think the bus driver ought to be required by law to report all serious deficiencies in their equipment to a state enforcement agency. And be held accountable when knowingly driving an unsafe bus. That said, it remains much accountability to the district, the provider, and the state for allowing such shoddy buses on the roads. What a bunch of jerks to go about boasting their school buses are safe. May be the case for the above average providers, but not the case for the below average. We seem to forget that safe means a mechanically sound bus, a safe environment for the children, and a safe workplace for the bus drivers. Where is OSHA in all this? Not a word.

jkraemer | Feb 08, 2012 06:49 AM

Its ashame that in this day and age we still have mechanics that mickey mouse school buses, have no formal training, and don't have a preventive maintenance program. This time it was 2 dead and 38 injured....next time????How many people must die before the fly by nighters wake up! I have to ask,,,where are the state inspectors during the time period before this crash? Does anyone regularly inspect the school buses in that state? I agree with the recomendations that the NTSB has to offer. Hopefully sooner that later. And school bus drivers,,,KEEP A SAFE FOLLOWING DISTANCE!

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